if the collapse of the world financial system isn't enough
to set one's nerves on edge, a study just published in the
Journal of Clinical Oncology reveals yet another alarming
trend: during the past several years the percentage of women
with non-invasive breast cancer (DCIS) who have their breasts
removed entirely (mastectomy) has increased 188%! Since mastectomy
is not at all required to treat the vast majority of patients
with DCIS, the looming question then becomes "Why are
all of these women having their breasts removed?"
Allow me to review some important facts. Non-invasive breast
cancer (DCIS, commonly known as ductal carcinoma in-situ)
is not life threatening. It is the earliest stage of breast
cancer and it does not have the ability to move beyond the
breast tissue to invade other organs of the body. Unless DCIS
is very large at the time of diagnosis, which is seldom the
case these days, it is very adequately treated with lumpectomy
and radiation therapy.
Most of the time DCIS is diagnosed by mammography and is
relatively small in size. Typically, it cannot be felt as
a lump and is seen only as microcalcifications on a mammogram.
The chance that DCIS will recur after proper treatment is
approximately 1 in 100 women diagnosed with the disease per
year. Which is to say, at ten years of follow-up, 10 women
in 100 with DCIS might have had a recurrence and the other
90 will be completely free of disease. So why are all of these
breasts coming off? And, furthermore, why are so many women
having their other perfectly normal breast removed at the
The study reported in the Journal of Clinical Oncology was
not meant to try to answer these questions but rather it was
meant to report the "state of play." Nonetheless,
I think it is fair to wonder why all of these breasts are
being removed if they don't have to be. My own suspicion,
after spending the past fifteen years rescuing women and their
breasts from overly aggressive surgeons, is that women are
being unnecessarily frightened and coaxed into aggressive
surgery in the false belief that this will provide an improved
survival. Of course, most women are naturally afraid of breast
cancer. And when they are diagnosed with the disease they
are usually surprised and alarmed. They are vulnerable to
any suggestion they think might improve their chances of "cure"
and they want to do everything they think might help them
"beat the disease." I believe these women are being
subtly encouraged to have mastectomies that they do not need
and that will not add one day to their life.
A few more facts: women who have been diagnosed with DCIS
have an increased risk of developing a similar breast cancer
in the opposite breast. However, the risk of "contralateral"
breast cancer is also very small - only about 1 in 100 women
with DCIS will develop disease in the opposite breast every
year following their initial diagnosis. (And medications,
like tamoxifen and arimidex, reduce this already small risk
even further.) To put it another way: after 10 years of follow-up,
90% of women have not developed disease in the opposite breast.
And those that do can be treated with lumpectomy and radiation
therapy - as can be done for the original tumor. Mastectomy
is not necessary to properly and adequately treat DCIS! Furthermore,
it is certainly not necessary to remove a perfectly normal
breast that in 90% of women will not develop a breast cancer
over the subsequent ten years following diagnosis of the original
If 90% of women with DCIS do not develop disease in the opposite
breast during the ten years following their first treatment,
why (all of a sudden) is there such a stampede for contralateral
prophylactic mastectomy? Does this have something to do with
the increasing numbers of plastic surgeons on the market?
Perhaps, I can't be sure. But I do know one thing - these
mastectomies are not necessary. The fact that prophylactic
mastectomies have increased by 188% is nothing short of alarming.
In the recent report even women with DCIS in one breast who
underwent breast-conservation in the breast that had the cancer
had a 148% increased incidence of prophylactic mastectomy
in the opposite breast - the perfectly normal breast! So,
the breast with the cancer is "saved" and the perfectly
normal breast is removed! This is just plain crazy. The breast
that has the
cancer gets to "live" and the opposite breast, without
the cancer, has to go. What planet are we living on?
Even though removal of the breast certainly reduces the likelihood
that a breast cancer can grow there, it does not add one day
to the overall survival of the patient. So, what's the point?
If prophylactic mastectomy is offered in order to reduce the
anxiety and worry that the cancer might come back, or that
it might occur in the opposite breast, I think women need
to know that the risk of this happening is rather small: only
1% per year for every 100 women with the disease. This fact
ought to reduce the patient's anxiety considerably. It certainly
has for my patients.
The proof that overall survival is not compromised by breast-conservation
and radiation therapy has been documented repeatedly in dozens
of studies conducted all over the world. In my own experience,
when the Cancer Registry at my hospital, Clara Maass Medical
Center in Belleville, New Jersey, reviewed my patients with
DCIS they found that I performed 50% fewer mastectomies than
other surgeons at my hospital, in my state and (on average)
around the country. They also discovered that the recurrence
rate for my patients was ten times lower than elsewhere in
the state or the nation.
Again, in the vast majority of cases mastectomies for DCIS
are not necessary. Recurrence of breast cancer is low if the
disease is treated properly; overall survival is well maintained.
Women do not have to sacrifice their breasts in order to save
their lives. In summary, women with DCIS should not be frightened
into having unnecessary surgeries that are risky, mutilating
and provide no survival advantage.
I am certainly in favor of preventing breast cancer. I am
particularly interested in preventing the recurrence of breast
cancer. But the most important thing is to reassure women
and give them the correct information about their true risks.
DCIS is a non-invasive breast cancer. It does not threaten
a woman's life. It can be treated very well with lumpectomy
and radiation therapy. A woman with DCIS can keep her breast.
She does not need mastectomy. She can keep her opposite breast
also. If she should develop breast cancer in the opposite
breast she can have breast-conservation with radiation therapy
on that breast, too.
If women understood that mastectomies do not increase their
survival, if women fully understood that breast-conservation
is perfectly acceptable as treatment for DCIS, then I believe
there would be far fewer therapeutic or contralateral "prophylactic"
mastectomies. Those few women who feel that they cannot tolerate
the anxiety that DCIS might recur can surely have mastectomy:
but they will be few and far between, I am sure.
I wish more women were given the proper counseling, reassured
about the relatively low risk of recurrence of DCIS and offered
the least treatment that will provide cure and relative peace
of mind - breast conservation and radiation therapy. Hopefully,
this message will gain enough currency in cyberspace to help
new patients with DCIS save their breasts as they strive to
save their lives.
Tuttle, TM. Increasing Rates of Contralateral Prophylactic
Mastectomy Among Patients with Ductal Carcinoma In-Situ. Journal
of Clinical Oncology, 2009. 27: 1362-67.
(c) 2009, Dr. Kathleen Ruddy. All rights reserved.
Santa Barbara Breast